George Twiddy
PFD Report
Partially Responded
Ref: 2019-0150
Coroner's Concerns (AI summary)
Poor inter-agency communication and unclear responsibilities between mental health services led to delays in providing immediate assistance during a patient's crisis.
View full coroner's concerns
At George's Inquest heard evidence that there was a lack of clarity in the days leading up to his death as to which of the two agencies that had been involved in his care (Hampshire AMHP Service and Southern Health NHS Trust's Early Intervention Psychosis Team) were in a position to provide him with immediate assistance. His parents were confused as where help would come and practitioners from the agencies were unclear as to where the responsibility lay-Although an improved explanatory leaflet for families about the responsibilities of the agencies is now in the course Of finalised and Iiaison to clarify respective roles has now taken place between senior managers of the agencies, it appears to me that a better understanding of those roles would be achieved if the practitioners actually involved in patient care themselves liaised more about what action and support should be made available to patients and relatives in crisis situations such as that faced by George and his family in the last days of his life. The from two being
Responses
Action Planned
Hampshire County Council (HCC) & Southern Health Foundation Trust (SHFT) will implement a s140 Policy, opportunities to attend inter – agency training, strategic development plans to deliver integrated pathways, mental health act information digital information and leaflet, and collaborative working with AMHPs & AMHT. (AI summary)
Hampshire County Council (HCC) & Southern Health Foundation Trust (SHFT) will implement a s140 Policy, opportunities to attend inter – agency training, strategic development plans to deliver integrated pathways, mental health act information digital information and leaflet, and collaborative working with AMHPs & AMHT. (AI summary)
View full response
Wednesday 29 May 2019
Page 1 of 3 Response to the Reg 28, GT
Hampshire County Council & Southern Health Foundation Trust
Response to the Regulation 28 report to Prevent Future Deaths (PFD), Coroner’s report touching the death of George Twiddy.
1.0 Introduction
1.1 This response is provided on behalf of Hampshire County Council (HCC) & Southern Health Foundation Trust (SHFT). Each organisation is responsible for the deployment of professionals involved in the provision of health and social care services toward George Twiddy who died on the 17th November 2017.
1.2 With direct evidence heard at the inquest, which is also recorded under a matter of concern from the PFD, the Coroner has highlighted the need for greater clarity on the role of each organisation in respect to the availability of mental health care and support for people in crisis.
2.0 HCC and SHFT HCC and SHFT share an equal commitment to address the serious concerns raised by the Coroner. HCC & SHFT have reviewed the PFD report findings together to plan how both agencies can adopt a more collaborative & effective approach, to support people in crisis as a result of their mental distress including where the Mental Health Act assessment process takes place.
2.1 Section 140 of the Mental Health Act states:- “it shall be the duty of every clinical commissioning group (CCG) and of every Local Health Board (LHB) to give notice to every local Social Services Authority for an area wholly or partly comprised within the area of the CCG or LHB specifying the hospital (s) in which arrangements are from time to time in force - (a) For the reception of patients in cases of special urgency (b) For the provision of accommodation or facilities designed so as to be especially suitable for patients who have not attained the age of the 18 years”. HCC and SHFT are committed to producing a s140 policy to ensure greater understanding for all frontline staff who have a role in supporting the person and their families, while undertaking a Mental Health Act assessment.
Wednesday 29 May 2019
Page 2 of 3 Response to the Reg 28, GT
3.0 Partnership working:
3.1 Both agencies have agreed to embark on a programme of joint work to organise Acute Mental Health Team staff (AMHT/ SHFT) to accompany the AMHP (HCC) and the Doctors as the assessing team members, so they can agree a support plan if admission to hospital is not deemed to be necessary and to be available at the time of the Mental Health Act assessment as required.
3.2 A range of joint work is already in evidence relating to the following aspects of service delivery including: - Development of shared processes to support people with their discharge planning from hospital Development of a joint programme of work to improve the accommodation choices for people Pan-Hants s136 meeting – including multi-organisational review all breaches / incidents reported Weekly Hospital Meetings/ Telephone Calls Monthly Strategy Meeting with Senior Managers from HCC / SHFT
4.0 Opportunities for multi-disciplinary training and shared learning
4.1 To focus on areas of Mental Health, Mental Health Act & practice issues, which will be supported by Senior Managers and Clinicians in HCC & SHFT.
4.2 HCC and SHFT have agreed to meet on a monthly basis to implement a programme of work which will aim to:
Improve joint working which will include improvements to services for people in crisis Continue a shared approach to supporting people in need of hospital admission and discharge planning Support the individual and their carers to live as independently as possible.
5.0 Mental Health Act Information and Advice
5.1 Design and publication of digital and paper information and advice is underway in consultation with people using services
6.0 Governance and Accountability for completion of actions
6.1 Care Governance Board (Adults Health and Care) will provide oversight to ensure monitoring and completion of actions for HCC.
6.2 The Quality and Safety Committee will provide oversight to ensure monitoring and completion of actions for SHFT
Wednesday 29 May 2019
Page 3 of 3 Response to the Reg 28, GT
Improvement Plan Agreed by HCC & SHFT - May 2019
Action By Whom By When Evidence of completion Progress Status (RAG)
1. Implement a s140 Policy HCC AMHP Service Manager & SHFT Associate Director of Capacity & Flow End July 2019 Publication of written policy Discussed and agreed to creating joint policy by Senior management Draft policy being Written & shared with relevant agencies by mid July 2019
2. Opportunities to attend inter – agency training HCC & SHFT End of October 2019 AMHPs & SHFT EAST have attended practice workshops together Additional future dates have been agreed, and Learning will be shared across all areas October 2019
3. Strategic development plans to deliver integrated pathways Senior Management from SHFT & HCC October 2019 Finalised Programme of work Monthly Strategic workshops are held monthly to develop plan October 2019
4. Mental Health Act information digital information and leaflet AMHP Service Manager End of July 2019 Publication of leaflet Draft form near to completion Consultation required once draft leaflet is in proposed print. Completion date July 2019
5. Collaborative working with AMHPs & AMHT HCC & SHFT End of July 2019 Rota’d arrangements Staff shadow arrangements in place July 2019
Page 1 of 3 Response to the Reg 28, GT
Hampshire County Council & Southern Health Foundation Trust
Response to the Regulation 28 report to Prevent Future Deaths (PFD), Coroner’s report touching the death of George Twiddy.
1.0 Introduction
1.1 This response is provided on behalf of Hampshire County Council (HCC) & Southern Health Foundation Trust (SHFT). Each organisation is responsible for the deployment of professionals involved in the provision of health and social care services toward George Twiddy who died on the 17th November 2017.
1.2 With direct evidence heard at the inquest, which is also recorded under a matter of concern from the PFD, the Coroner has highlighted the need for greater clarity on the role of each organisation in respect to the availability of mental health care and support for people in crisis.
2.0 HCC and SHFT HCC and SHFT share an equal commitment to address the serious concerns raised by the Coroner. HCC & SHFT have reviewed the PFD report findings together to plan how both agencies can adopt a more collaborative & effective approach, to support people in crisis as a result of their mental distress including where the Mental Health Act assessment process takes place.
2.1 Section 140 of the Mental Health Act states:- “it shall be the duty of every clinical commissioning group (CCG) and of every Local Health Board (LHB) to give notice to every local Social Services Authority for an area wholly or partly comprised within the area of the CCG or LHB specifying the hospital (s) in which arrangements are from time to time in force - (a) For the reception of patients in cases of special urgency (b) For the provision of accommodation or facilities designed so as to be especially suitable for patients who have not attained the age of the 18 years”. HCC and SHFT are committed to producing a s140 policy to ensure greater understanding for all frontline staff who have a role in supporting the person and their families, while undertaking a Mental Health Act assessment.
Wednesday 29 May 2019
Page 2 of 3 Response to the Reg 28, GT
3.0 Partnership working:
3.1 Both agencies have agreed to embark on a programme of joint work to organise Acute Mental Health Team staff (AMHT/ SHFT) to accompany the AMHP (HCC) and the Doctors as the assessing team members, so they can agree a support plan if admission to hospital is not deemed to be necessary and to be available at the time of the Mental Health Act assessment as required.
3.2 A range of joint work is already in evidence relating to the following aspects of service delivery including: - Development of shared processes to support people with their discharge planning from hospital Development of a joint programme of work to improve the accommodation choices for people Pan-Hants s136 meeting – including multi-organisational review all breaches / incidents reported Weekly Hospital Meetings/ Telephone Calls Monthly Strategy Meeting with Senior Managers from HCC / SHFT
4.0 Opportunities for multi-disciplinary training and shared learning
4.1 To focus on areas of Mental Health, Mental Health Act & practice issues, which will be supported by Senior Managers and Clinicians in HCC & SHFT.
4.2 HCC and SHFT have agreed to meet on a monthly basis to implement a programme of work which will aim to:
Improve joint working which will include improvements to services for people in crisis Continue a shared approach to supporting people in need of hospital admission and discharge planning Support the individual and their carers to live as independently as possible.
5.0 Mental Health Act Information and Advice
5.1 Design and publication of digital and paper information and advice is underway in consultation with people using services
6.0 Governance and Accountability for completion of actions
6.1 Care Governance Board (Adults Health and Care) will provide oversight to ensure monitoring and completion of actions for HCC.
6.2 The Quality and Safety Committee will provide oversight to ensure monitoring and completion of actions for SHFT
Wednesday 29 May 2019
Page 3 of 3 Response to the Reg 28, GT
Improvement Plan Agreed by HCC & SHFT - May 2019
Action By Whom By When Evidence of completion Progress Status (RAG)
1. Implement a s140 Policy HCC AMHP Service Manager & SHFT Associate Director of Capacity & Flow End July 2019 Publication of written policy Discussed and agreed to creating joint policy by Senior management Draft policy being Written & shared with relevant agencies by mid July 2019
2. Opportunities to attend inter – agency training HCC & SHFT End of October 2019 AMHPs & SHFT EAST have attended practice workshops together Additional future dates have been agreed, and Learning will be shared across all areas October 2019
3. Strategic development plans to deliver integrated pathways Senior Management from SHFT & HCC October 2019 Finalised Programme of work Monthly Strategic workshops are held monthly to develop plan October 2019
4. Mental Health Act information digital information and leaflet AMHP Service Manager End of July 2019 Publication of leaflet Draft form near to completion Consultation required once draft leaflet is in proposed print. Completion date July 2019
5. Collaborative working with AMHPs & AMHT HCC & SHFT End of July 2019 Rota’d arrangements Staff shadow arrangements in place July 2019
Sent To
- Hampshire County Council
- southern Health NHS Trust
Response Status
Linked responses
1 of 2
56-Day Deadline
23 Sep 2019
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On 21 November 2017 commenced an investigation into the death of George Daniel TWIDDY age 23. The investigation concluded at the end of the inquest on 28 March 2019, The conclusion of the_inquest was cause of death: 1a. Hanging: Narrative Conclusion: George Daniel TWIDDY took his own life whilst suffering from severe and distressing psychiatric illness.
Circumstances of the Death
At about 14.20 hours on Fifteenth November 2017 George Daniel TWIDDY was found hanging from a tree in Warren Copse, Petersfield. He was taken to Queen Alexandra Hospital, Portsmouth, where he was diagnosed to have suffered an un-treatable brain injury. He died at the hospital at 05.08 hours on Seventeenth November 2017
Action Should Be Taken
In my opinion action should be taken t0 prevent future deaths and believe your organisation have the power to take such action.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.